Part I – To Be Completed by ALL Applicants

Application for a Farm Labor Contractor or Farm Labor Contractor Employee Certificate of Registration Migrant and Seasonal Agricultural Worker Protection Act

U.S. Department of Labor

Wage and Hour Division

Part I ? To Be Completed by ALL Applicants

Please read instructions before completing this application. No Farm Labor Contractor (FLC) or Farm Labor Contractor Employee (FLCE) Certificate of Registration may be issued unless a completed form has been received (29 U.S.C. 1801 et. seq.)

1. Application for certificate of registration for: (Check only one)

FLC

Initial

Renewal

Amended

FLCE

Initial

Renewal

Amended

If renewal, Prior Certificate Number:

Is form FD-258 fingerprint card attached? Yes____ No____ (See Instructions)

2. Name of applicant or applicant's representative (Please Type or Print)

e (Last)

(First)

(Middle)

Permanent place of residence (Address May Not Be a P.O. Box):

Street: State:

Zip Code:

City: Country:

If mailing address is different, please complete the following (Address May Be a P.O. Box):

Street: State:

Zip Code:

City: Country:

5. Driving authorization: (To be completed by an "individual" applicant)

Will you drive a vehicle to transport workers?

Yes

No

If "yes", read instructions and complete the following:

Driver's license no.: (Attach copy of license to application)

State:

Date issued:

Expiration date:

Class:

Endorsements:

Restrictions:

A valid doctor's certificate must be submitted every three years.

Doctor's certificate expiration date:

Is doctor's certificate attached?

Yes

No

Will drive workers for:

Self

Other

If "Other," specify the name and FLC registration number:

Primary Telephone Number: Alternate telephone: Social Security Number:

3. Sex: Male

Female

Height:

ft.

in

Weight:

lbs.

Eye color:

Hair color:

4. Date of birth (mo., day, year):

United States citizen:

Yes

No

6. Have you been convicted within the past 5 years, under State or Federal law, of any of the following crimes?

Any crime relating to gambling, or to the sale, distribution, or possession of alcoholic beverages, in connection with or incident to any farm labor contracting activities.

Yes

No

Any felony involving robbery, bribery, extortion, embezzlement, grand larceny, burglary, arson, violation of narcotics laws, murder, rape, assault with intent to kill, assault which inflicts grievous bodily injury, prostitution, peonage, or smuggling or harboring individuals who have entered the United States illegally.

Yes

No

If naturalized citizen, provide date: If visa holder, provide visa no. or temporary worker visa no.:

Visa expiration date (If applicable):

(If "Yes," to a CONVICTION of any of the above, attach a copy of the final judgment in the case to your application. If you do not possess a copy of the final judgement, attach an additional

sheet listing the crime, date, place of conviction, and the court of jurisdiction.)

A false answer or misrepresentation to any question may be punishable by fine or imprisonment. 18 U.S.C. ? 1001, 29 U.S.C. ?? 1851-1853; 29 C.F.R. 500.6.

Form WH-530 OMB No. 1235-0016

Expires 08/31/2023

NOTE:

IF YOU ARE APPLYING AS A FARM LABOR CONTRACTOR, CONTINUE WITH PART II

IF YOU ARE APPLYING AS A FARM LABOR CONTRACTOR EMPLOYEE, SKIP PART II AND GO DIRECTLY TO PART III (A Farm Labor Contractor Employee is a person who performs farm labor contracting activities solely on behalf of a [specific] Farm Labor Contractor holding a valid Certificate of Registration and is not an independent Farm Labor Contractor who would be required to register under the Act in his/her own right.)

Part II ? To Be Completed by Farm Labor Contractor (FLC) Applicant

7. The applicant is a/an: (Check One)

Individual

Corporation

Partnership

Other (Specify)

Applicant name to appear on certificate (for example, legal name of corporation or doing business as / dba) (Area code) (Number) If the applicant has submitted any other applications under a different name(s), provide the names here

Business address to be listed on certificate (if different from the permanent place of residence in Item 2)

(Street)

Date of incorporation: State of incorporation:

(City)

(State)

IRS employer identification No.:

State unemployment insurance reporting no.:

(Zip Code)

8. Check each activity to be performed involving migrant and/or seasonal agricultural workers for agriculture employment:

Recruit

Hire

Furnish

Transport

Solicit

Employ

9. Give the greatest number of migrant and/or seasonal agricultural workers that will be in the crew(s) at any time:

Indicate whether you employ or intend to employ H-2A visa workers. Yes

How many?

No

Indicate whether you employ or intend to employ H-2B visa workers. Yes

How many?

No

Location(s) of work (including farm name(s), city, and state): ______________________________ Crops:___________________

Work activities:

10. Will you be directly transporting workers or engaging others to provide transportation?

____ No. Explain how workers will get to the worksite:

Yes. Number of Workers:

Type of vehicle(s) and seating capacity:

If "No," proceed to Item 11. If "Yes," answer the questions below:

Will any single trip be more than 75 Miles round-trip? Yes. Is a properly completed WH-514 Vehicle Mechanical Inspection Report attached for each vehicle? No. Is a properly completed WH-514a Vehicle Mechanical Inspection Report attached for each vehicle?

(item 10 continues on next page)

Yes Yes

No No

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10. continued

How will the applicant comply with the insurance or liability bond requirements? (Check all that apply and attach proof of compliance for each of the vehicle insurance or liability bond options listed below.)

Vehicle liability insurance coverage in the amount of not less than $100,000 for each seat in the vehicle.

Liability bond.

State workers' compensation insurance coverage and a minimum of $50,000 per accident in motor carrier or other appropriate insurance covering loss or damage to the property of others (excluding cargo). The workers' compensation policy must cover all circumstances in which the migrant or seasonal agricultural workers will be transported or, if necessary, additional coverage through a liability insurance policy or liability bond must be procured for transportation not covered by the State law. (If using workers' compensation coverage in lieu of vehicle insurance, the applicant must complete the following additional questions.)

If using state workers' compensation insurance coverage in lieu of vehicle insurance, check all circumstances in which the applicant will transport workers and sign below:

Daily transportation between living quarters and worksite Recurring transportation to run errands (e.g., to the grocery store, laundromat, etc.)

Long distance travel between worksites, or to/from the worker's permanent residence in a different city, state, or country

Other (describe): ________________________________________________________________________________________________ ________________________________________________________________________________________________ ____________________________________________

I affirm that I have truthfully listed all circumstances in which I will transport workers, and that my workers' compensation policy covers these circumstances under applicable State law. I further affirm that I will not transport workers in any circumstances not covered under applicable State law by my workers' compensation policy.

SIGNATURE OF APPLICANT: 11. Will you own or control any facility or real property which will be used by migrant agricultural workers in the crew(s) at any time?

Yes. Submit statement identifying all housing to be used and proof that such housing meets all applicable Federal and State safety and health

standards.

No. Give the name and address of all persons who own or control housing to be used by migrant agricultural workers in the crew.

CERTIFICATION

I certify that compensation is to be received for the intended farm labor contractor services and that all representations made by me in this application are true to the best of my knowledge and belief.

Applicant's Signature and Title (if other than individual) and Date

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Statement of Intention to Comply with Housing Requirements of the Migrant and Seasonal Agricultural Worker Protection Act (MSPA)

Section 102(3) of the MSPA requires that an applicant for a certificate of registration with authorization to house migrant agricultural workers shall file a statement identifying each facility or real property to be used by the applicant to house any migrant agricultural worker during the period for which registration is sought. 29 U.S.C. ? 1812(3); 29 C.F.R. ? 500.45(c). If the facility or real property is or will be owned or controlled by the applicant, such statement shall provide documentation showing that the applicant is in compliance with all substantive Federal and State safety and health standards with respect to each such facility or real property. I hereby declare that I will not house migrant agricultural workers in any facility or real property I own or control until I have submitted all necessary written evidence and have been issued a Certificate of Registration with housing authorized. I understand that I may then house migrant agricultural workers only in facilities or real property which has been authorized by the Secretary of Labor

Signature of Applicant ______________________________________ Date _________________________

Statement of Intention to Comply with Transportation Requirements of the Migrant and Seasonal Agricultural Worker Protection Act (MSPA)

When using, or causing to be used, any vehicle for providing transportation to migrant and/or seasonal agricultural workers, I declare that I will ensure that each vehicle conforms to applicable Federal and State safety regulations, that it has an insurance policy or liability bond in effect which insures me against liability for damage to persons or property arising from transporting any migrant or seasonal agricultural workers in that vehicle, and that each driver has a valid and appropriate license, as provided by State law, to operate the vehicle. I further declare that I will not transport migrant or seasonal agricultural workers in any vehicle I own or control until I have submitted all necessary written evidence and have been issued a Certificate of Registration with transportation authorized, and that I will maintain the vehicle(s) in accordance with applicable Federal and State safety regulations, maintain insurance at the required levels, and transport only in circumstances that are covered by my insurance.

Signature of Applicant ______________________________________ Date _____________________________

Authorization of the Secretary of Labor to Accept Legal Process

The following authorization is executed pursuant to section 102(5) of the MSPA. 29 U.S.C. ? 1812(5); 29 C.F.R. ? 500.45(e).

"I do hereby designate and appoint the Secretary of Labor, United States Department of Labor, as my lawful agent to accept service of summons in any action against me at any and all times during which I have departed from the jurisdiction in which such action is commenced or otherwise have become unavailable to accept service, and under such terms and conditions as are set by the court in which such action has been commenced."

Signature of Applicant ______________________________________ Date ______________________________________

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PART III ? To Be Completed by Any Applicant for a Farm Labor Contractor Employee (FLCE) Certificate of Registration

12. Employer Identification (Name, Farm Labor Contractor Registration No.): Name: Number: C-/ / /-/ / / / / / /-/ /-/ / /-/ /

13. Approximate Date the Planned Farm Labor Activity Will Begin:

(Month, Day, Year)

CERTIFICATION

I certify that I am an employee of the farm labor contractor identified above and will perform farm labor contracting activities only for that farm labor contractor and for no other farm labor contractor. I certify that all representations made by me in this application are true to the best of my knowledge and belief.

Signature of Applicant

Date

Authorization of the Secretary of Labor to Accept Legal Process

The following authorization is executed pursuant to section 102(5) of the MSPA. 29 U.S.C. ? 1812(5); 29 C.F.R. ? 500.45(e).

"I do hereby designate and appoint the Secretary of Labor, United States Department of Labor, as my lawful agent to accept service of summons in any action against me at any and all times during which I have departed from the jurisdiction in which such action is commenced or otherwise have become unavailable to accept service, and under such terms and conditions as are set by the court in which such action has been commenced."

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Signature of Applicant

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Date

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